Return to Sender: The need to re-address patient antibiotic allergy labels in Australia and New Zealand

BACKGROUND: Antibiotic allergies are frequently reported and have significant impacts upon appropriate prescribing and clinical outcomes. We surveyed infectious diseases physicians, allergists, clinical immunologists and hospital pharmacists to evaluate antibiotic allergy knowledge and service delivery in Australia and New Zealand. METHODS: An online multi-choice questionnaire was developed and endorsed by representatives of the Australasian Society of Clinical Immunology and Allergy (ASCIA), Australasian Society of Infectious Diseases (ASID) and Society of Hospital Pharmacists Australia (SHPA). The 37-item survey was distributed in April 2015 to members of ASCIA, ASID, SHPA and Royal Australasian College of Physicians. RESULTS: Of 277 respondents, 94% currently use or would utilise antibiotic allergy testing (AAT) and reported seeing up to 10 patients/week labelled as antibiotic-allergic. Forty-two per cent were not aware of or did not have AAT available. Most felt that AAT would aid antibiotic selection, antibiotic appropriateness and antimicrobial stewardship (79%, 69% and 61%, respectively). Patients with histories of immediate hypersensitivity were more likely to be referred than those with delayed hypersensitivities (76% vs. 41%, p=0.0001). Lack of specialist physicians (20%) and personal experience (17%) were barriers to service delivery. A multidisciplinary approach was the preferred AAT model (53%). Knowledge gaps were identified, with the majority over-estimating rates of penicillin/cephalosporin (78%), penicillin/carbapenem (57%) and penicillin/monobactam (39%) cross-reactivity. CONCLUSIONS: A high burden of antibiotic allergy labelling and demand for AAT is complicated by a relative lack availability or awareness of AAT services in Australia and New Zealand. Antibiotic allergy education and deployment of AAT, accessible to community and hospital-based clinicians, may improve clinical decisions and reduce antibiotic allergy impacts. A collaborative approach involving ID physicians, pharmacists and allergists/immunologists is required

Improving antimicrobial stewardship by antibiotic allergy delabeling: Evaluation of knowledge, attitude, and practices throughout the emerging infections network

Antibiotic allergy testing (AAT) practices of Emerging Infections Network infectious disease physicians were surveyed. Although AAT was perceived to be necessary for removal of inappropriate or unnecessary allergy labels, there was limited access to any form of testing. In this study, we discuss current antibiotic allergy knowledge gaps and the development of AAT practices within antimicrobial stewardship programs, which will potentially improve antimicrobial prescribing

Antibiotic allergy De-Labeling: Teaching an old dog new tricks

Rationale Antibiotic allergy labels (AAL) significantly impact antibiotic prescribing and may lead to the inappropriate use of broad spectrum antibiotics which creates a public health concern. Infectious disease (ID) physicians from the Emerging Infections Network (EIN) of the Infectious Diseases Society of America (IDSA) were surveyed to determine their views, access and use of antibiotic allergy testing (AAT). Methods A 10-item online survey was distributed by the EIN in September 2015 to 1172 members practicing adult ID, 323 pediatric and 24 both. Two reminders were sent to non-respondents. Results Of 736/1,545 (48%), only 43% had skin prick/intradermal testing (SPT) available and 30% were either unaware of options or had none available. Although 78% overall suggested that a negative test would lead to AAL removal, those with > 15 years experience were significantly less likely to remove AAL (P<0.001). Most felt AAL removal would aid antibiotic selection (95%), appropriateness (92%), safety (74%) and antimicrobial-stewardship (AMS) (82%). Although 68% overall advocated incorporation of AAT into AMS, those with < 15 years experience were significantly more likely to support this (p=0.006). In settings of a remote reaction history, point-of-care testing (40%) was preferred to antibiotic desensitization (7%). Conclusions ID physicians perceive inadequate access to AAT services. Less experienced physicians were both more likely to view AAT as a means to remove AAL and advocate its incorporation into AMS. A generational shift appears to be occurring that should support AAT as a tool to improve antibiotic appropriateness

A randomised trial of two 2-dose influenza vaccination strategies for patients following autologous haematopoietic stem cell transplantation

Background: Seroprotection and seroconversion rates are not well understood for 2-dose inactivated influenza vaccination (IIV) schedules in autologous hematopoietic stem cell transplantation (autoHCT) patients. Methods: A randomized, single-blind, controlled trial of IIV in autoHCT patients in their first year post-transplant was conducted. Patients were randomized 1:1 to high-dose (HD) IIV followed by standard dose (SD) vaccine (HD-SD arm) or 2 SD vaccines (SD-SD arm) 4 weeks apart. Hemagglutination inhibition (HI) assay for IIV strains was performed at baseline, 1, 2, and 6 months post–first dose. Evaluable primary outcomes were seroprotection (HI titer ≥40) and seroconversion (4-fold titer increase) rates and secondary outcomes were geometric mean titers (GMTs), GMT ratios (GMRs), adverse events, influenza-like illness (ILI), and laboratory-confirmed influenza (LCI) rates and factors associated with seroconversion. Results: Sixty-eight patients were enrolled (34/arm) with median age of 61.5 years, majority male (68%) with myeloma (68%). Median time from autoHCT to vaccination was 2.3 months. For HD-SD and SD-SD arms, percentages of patients achieving seroprotection were 75.8% and 79.4% for H1N1, 84.9% and 88.2% for H3N2 (all P > .05), and 78.8% and 97.1% for influenza-B/Yamagata (P = .03), respectively. Seroconversion rates, GMTs and GMRs, and number of ILI or LCIs were not significantly different between arms. Adverse event rates were similar. Receipt of concurrent cancer therapy was independently associated with higher odds of seroconversion (OR, 4.3; 95% CI, 1.2–14.9; P = .02). Conclusions: High seroprotection and seroconversion rates against all influenza strains can be achieved with vaccination as early as 2 months post-autoHCT with either 2-dose vaccine schedules.Benjamin W. Teh, Vivian K.Y. Leung, Francesca L. Mordant, Sheena G. Sullivan, Trish Joyce, Simon J. Harrison, Arseniy Khvorov, Ian G. Barr, Kanta Subbarao, Monica A. Slavin, and Leon J. Wort

Impact of an Integrated Antibiotic Allergy Testing Program on Antimicrobial Stewardship: A Multicenter Evaluation

Background. Despite the high prevalence of patient-reported antibiotic allergy (so-called antibiotic allergy labels [AALs]) and their impact on antibiotic prescribing, incorporation of antibiotic allergy testing (AAT) into antimicrobial stewardship (AMS) programs (AAT-AMS) is not widespread. We aimed to evaluate the impact of an AAT-AMS program on AAL prevalence, antibiotic usage, and appropriateness of prescribing. Methods. AAT-AMS was implemented at two large Australian hospitals during a 14-month period beginning May 2015. Baseline demographics, AAL history, age-adjusted Charlson comorbidity index, infection history, and antibiotic usage for 12 months prior to testing (pre-AAT-AMS) and 3 months following testing (post-AAT-AMS) were recorded for each participant. Study outcomes included the proportion of patients who were "de-labeled" of their AAL, spectrum of antibiotic courses pre- and post-AAT-AMS, and antibiotic appropriateness (using standard definitions). Results. From the 118 antibiotic allergy-tested patients, 226 AALs were reported (mean, 1.91/patient), with 53.6% involving 1 or more penicillin class drug. AAT-AMS allowed AAL de-labeling in 98 (83%) patients-56% (55/98) with all AALs removed. Post-AAT, prescribing of narrow-spectrum penicillins was more likely (adjusted odds ratio [aOR], 2.81, 95% confidence interval [CI], 1.45-5.42), as was narrow-spectrum beta-lactams (aOR, 3.54; 95% CI, 1.98-6.33), and appropriate antibiotics (aOR, 12.27; 95% CI, 5.00-30.09); and less likely for restricted antibiotics (aOR, 0.16; 95% CI,.09-.29), after adjusting for indication, Charlson comorbidity index, and care setting. Conclusions. An integrated AAT-AMS program was effective in both de-labeling of AALs and promotion of improved antibiotic usage and appropriateness, supporting the routine incorporation of AAT into AMS programs